cyo 


On  I 


miljeCtipofBfttigtfrk 

LIBRARY 


Digitized  by  the  Internet  Archive 

in  2011  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/inauguraldissertOOonde 


J\/'.'2'//<;/,,,,P  Jiiizarj'a, 
Jjlffioh'my. 


AN 

INAUGURAL  DISSERTATION 

ON 

STONE  IN  THE  BLADDER. 


Submitted  to  the  public  Examination  of  the  Faculty  of  Physic  under  the 

Authority  of  the  Trustees  of  Columbia  College, 

in  the  State  of  New -York, 

The  Right  Rev.  BENJAMIN  MOORE,  D.  D.  President? 

FOR    THE    DEGREE    OF 

DOCTOR  OF  PHYSIC, 

On  the  13th  Day  of  November,  1810, 


BY  HENRY  U.  ONDERDONK,  A.  M. 

Member  of  the  Royal  College  of  Surgeons,  London. 


"  The  ancients  only  laid  the  foundation,  which  was  doing  considerable 

service  :  they  who  have  come  after  them,  have  worked  upon  their  plan, 

and  from  time  to  time,  the  art  of  Surgery  has  received  improvements." 

Gataker's  Translation  of Le  Droll's  Operations, 

I 


$eto*Iorri: 

Printed  by  T.  &  J.  SWORDS,  Printers  to  the  Faculty  of  Physic 
of  Columbia  College,  No.  160  Pearl-Street. 

1810, 


&OLXJMBXA3XA. 


v  A  "  tL  i' 


'{ 


A- 


"C^^z^C^Z 


TO 


DOCTOR  JOHN  ONDERDONk 

AS   A 
TRIBUTE  OF  FILIAL  DUTY  AND  GRATITUDE 


TO 


WRIGHT  POST,  ESQ. 

Professor  of  Anatomy  and  Surgery  in  Columbia  College, 
and  Surgeon  to  the  New- York  Hospital, 

AS    A 

TESTIMONIAL  OF  RESPECT  AS  AN  INSTRUCTOR5 
AND  OF  ESTEEM  AS  A  FRIEND; 


AND  TO 

THOMAS  BLIZARD,  ESQ. 

Fellow  of  the  Royal  Societies  of  London  and  Edinburgh, 
and  Surgeon  to  the  London  Hospital, 

AS    AN 

ACKNOWLEDGMENT  OF  PROFESSIONAL  AND 
PERSONAL  CIVILITIES; 

THIS  DISSERTATION 
15  RESPECTFULLY  INSCRIBED 


ADVERTISEMENT. 


T.  HE  author  of  the  following  pages  was  led 
to  select  his  subject  from  having  witnessed  at 
the  Hospitals  in  London,  the  frequent  use  of 
a  bistoury  in  lithotomy ;  and  from  a  convic- 
tion, that  it  was  an  instrument  superior  in 
principle  to  any  other  he  had  seen  used.  But 
to  have  merely  dwelt  upon  the  merits  of  the 
knife,  would  not  have  afforded  matter  suffi- 
cient for  an  Inaugural  Dissertation  of  reason- 
able length.  He  has  therefore  given  a  general 
history  of  the  disease,  for  whose  removal  the 
instrument  is  proposed.  He  is  sensible  that 
much  of  this  is  mere  selection;  but  he  has 
endeavoured  to  quote  from  such  authorities 
as  are  standard,  and  to  adduce  only  such  facts 
and  observations  as  are  of  importance.  These, 
he  trusts,  will  compensate  for  any  deficiency 
In  his  own  remarks. 

Nassau-Street,  Oct.  2,  1810. 


on 

STONE  IN  THE  BLADDER. 


CALCULOUS  concretions  are  found  in  many 
parts  of  the  body;  but  their  most  usual  situation  is 
in  the  urinary  organs ;  in  the  kidney,  ureter,  blad- 
der, prostate  gland,  urethra,  and  around  the  corona 
glandis.  The  nature  of  those  found  in  the  bladder, 
the  symptoms  they  occasion,  and  the  methods  of 
relief,  are  the  subjects  of  the  present  dissertation. 

Calculi  in  the  bladder  vary  in  size,  number,  and 
composition.  The  most  usual  sizes  are  between 
those  of  a  musket  ball  and  a  hen's  egg.  But  they 
are  sometimes  much  larger.  At  the  lectures  of  the 
Royal  College  of  Surgeons  in  London,  a  stone  is 
exhibited,  which  weighs  44  oz.  and  is  16  inches  in 
one  circumference,  and  14  in  the  other.  An  at- 
tempt was  made  to  extract  this  by  Sir  Jamoo  fcafte-, 
but  he,  of  course,  failed,  and  the  patient  died  from 
consequent  irritation.  Calculi  are  sometimes  much 
smaller  than  the  size  above  limited. 

Commonly  there  is  but  one  calculus  in  the  blad- 
der,   Much  variety  however  in  this  respect  is  met 


8 

with.  I  have  seen  two  sets,  one  of  37,  and  another 
of  22,  each  taken  from  a  single  bladder.  Dessault 
extracted  200  from  one  bladder,*  which  were  most 
probably  small.  Mr.  Home  relates  an  instance  of 
350  from  one  patient. f  When  more  than  one  exist, 
their  surfaces  are  smooth.  Cheselden  gives  a  plate 
of  two  from  one  bladder,  which  had  opposing  smooth 
surfaces  like  a  joint: J  they  had  probably  been  re- 
tained in  the  bladder  in  such  a  situation  that  their 
friction  upon  one  another  was  confined  to  these  sur- 
faces. Dr.  R.  S.  Kissam  showed  me  a  single  cal- 
culus with  a  small  part  of  its  surface  polished,  which 
he  attributed  to  its  lying  constantly  upon  an  enlarged 
prostate. 

Mr.  Brande,  in  a  paper  published  in  the  Philoso- 
phical Transactions  for  1808,  §  has  arranged  urinary 
calculi  into  three  kinds :  Those  composed  chiefly  of 
uric  acid ;  those  made  up  chiefly  of  an  ammoniaco- 
magnesian  phosphate,  or  of  phosphate  of  lime,  or 
of  both ;  and  those  which  contain  oxalate  of  lime^ 
called  also  mulberry  calculi. 

The  first  kind  are  those  passed  from  the  kidney 
out  of  the  body,  without  remaining  in  the  bladder 
at  all,  or  only  a  short  time.  They  consist  of  uric 
acid  and  animal  matter,  in  proportions  varying  from 
nearly  equal  quantities  of  each,  to  two  thirds  of  the 
former.  This  species  are  soluble  in  alkalies,  and 
disappear  before  the  blow-pipe:  they  have  smooth 
surfaces,  and  are  made  up  of  concentric  layers  like 
a  section  of  a  tree;  their  colour  is  commonly  browns 


*  Parisian  Journal,  vol.  ii.  p.  386. 
f  Philosophical  Transactions,  1808,  page  244. 
-  Cheselden's  Anatomy,  edit.  1.722,  plate  SO 
;)  Page  223. 


9 

I  have,  however,  seen  them  white.  Dr.  G.  Pearson, 
in  a  paper  of  the  Philosophical  Transactions  for 
1798,*  terms  the  acid  which  constitutes  the  base  of 
this  kind  of  calculus,  uric  oxide:  he  asserts  that  it 
is  only  found  in  the  human  subject,  and  may  be  dis- 
covered in  gouty  concretions,  but  not  in  those  of 
the  teeth,  stomach,  intestines,  lungs,  brain,  &c. 
He  notices  some  analogies  which  induce  him  to  be- 
lieve, that,  if  man  lived  on  vegetables  alone,  he 
would  not  have  this  oxide  formed  in  his  body.- — The 
first  detection  of  uric  acid  by  analysis  of  urinary 
calculus  was  by  Scheele. 

The  next  division  made  by  Mr.  Brande,  compre- 
hends such  calculi  as  are  principally  made  up  of  the 
ammoniaco-magnesian  phosphate,  or  of  phosphate 
of  lime,  or  of  both.  These  substances,  he  asserts, 
are  met  with  when  the  stone  has  been  some  time  in 
the  bladder,  or  when  a  stone  is  detained  longer  than 
usual  in  the  kidneys.  These  are  commonly  the 
most  abundant  ingredients  in  a  large  calculus.  They 
are  generally  mixed  with  the  uric  acid,  either  in  dis- 
tinct layers,  or  by  mechanical  diffusion.  Calculi 
formed  of  these  alone,  are  found  in  the  bladder  only, 
and  have  some  loosely  agglutinated  particles  of  the 
same  matter  for  a  nucleus.  The  colour  of  calculi  of 
this  species  is  a  whitish  grey;  their  surfaces  fre- 
quently exhibit  transparent  crystals ;  they  generally 
are  firm,  but  not  unfrequently  so  friable  as  to  crum- 
ble under  very  slight  pressure;  they  are  soluble  in 
muriatic  acid.  They  are  thought  to  be  connected 
with  greater  disease  of  the  bladder  than  either  of  the 
other  species. 


Page  lc 

2 


10 

The  last  division  of  Mr.  Brande  contains  the 
few  specimens  which  exhibit  on  analysis  oxalate  of 
lime.  These  are  found  only  in  the  kidney,  or  are 
immediately  passed  thence.  If  they  have  been  re- 
tained in  the  bladder,  they  are  only  nuclei  for  some 
other  species.  When  they  are  passed  immediately 
out,  the  patient  is  less  liable  to  a  return  of  the  com- 
plaint. The  surface  of  this  species  of  stone  is  rough, 
not  unlike  the  fruit  to  which  it  is  compared;  they 
are  firm  in  texture,  and  difficultly  soluble  in  acids. 

The  following  is  the  result  of  the  analysis  of  150 
calculi,  made  by  this  chemist.  It  exhibits  the  pro- 
portional frequency  of  the  several  species,  and  may 
afford  some  useful  hints  in  considering  the  means 
proposed  for  dissolving  a  stone. 

16  consisted  of  uric  acid ; 

45  of  uric  acid  as  the  larger,  and  the  phosphates 
as  the  smaller  ingredient ; 

66  of  the  phosphates  as  the  larger,  and  uric  acid 
as  the  smaller  ingredient ; 

12  of  the  phosphates  alone; 

5  of  uric  acid  and  the  phosphates,  with  a  nucleus 
of  oxalate  of  lime; 

6  of  oxalate  of  lime  chiefly. 

The  analysis  of  urinary  calculi  was  extended  by 
Mr.  Brande  to  those  found  in  the  brute  creation, 
Specimens  from  the  horse,  ox,  sheep,  dog,  hog, 
rabbit,  and  rhinoceros  were  examined;  and  the 
grand  difference  between  them  and  the  human, 
was,  that  they  contained  no  uric  acid,  but  carbonate 
of  lime  very  generally,  an  ingredient  not  discovered 
in  the  human  specimen? 


11 


SYMPTOMS. 

A  patient  generally  first  experiences  an  itching  or 
smarting  sensation  about  the  frenum.  This  induces 
him  to  rub  the  part  frequently,  and  the  prepuce  is 
thus  sometimes  preternaturally  elongated.  When 
very  violent,  the  sensation  has  been  compared  to 
cutting  with  a  red-hot  knife.  A  frequency  in  making 
water,  together  with  pain,  is  soon  observed;  and 
this  pain  is  particularly  great  while  voiding  the  last 
drops,  during  which  the  bladder  contracts  firmly 
upon  the  stone,  and  undergoes  excessive  irritation. 
The  pain  at  the  glans  is  most  acute,  from  that  part 
being  a  centre  of  sympathy  for  the  bladder  and  ure- 
thra; that  in  the  region  of  the  bladder  is  of  a  more 
dull  nature. 

A  more  remarkable  and  more  certain  diagnostic  of 
the  disease,  is  an  irregularity  in  passing  the  urine. 
It  first  flows  in  a  full  stream,  and  then  is  suddenly 
stopped.  This  arises  from  a  falling  (as  it  is  usually 
termed)  of  the  stone  against  the  mouth  of  the  ure- 
thra. But  the  obstruction  is  rather  caused  by  the 
stone  being  raised  to  this  point,  from  the  lower  pos- 
terior bulging  part  of  the  cavity ;  into  which  its  own 
gravity  will  incline  it  to  subside,  and  which  becomes 
obliterated  while  the  bladder  is  contracting  to  void 
the  urine :  when  the  stone  is  raised  to  the  point  men- 
tioned, it  will  be  disposed  to  remain  in  the  funnel- 
like cavity,  until  a  new  distention  of  the  bladder 
allows  it  to  subside  to  its  first  situation.  This 
symptom  occurs  also  in  that  disease  of  the  prostate, 
where  a  part  of  that  gland  is  made  to  project  into  the 
bladder. 


Agitation  greatly  increases  the  pain  from  a  stone. 
Riding  in  a  carriage  or  on  horseback  will  occasion 
excruciating  torture,  and  not  unfrequently  cause  the 
urine  to  be  tinged  with  blood.  If  the  bladder  be 
particularly  irritable,  the  mere  change  from  a  stand- 
ing to  a  recumbent  posture  will  give  pain.  These 
symptoms  do  not  take  place  in  enlarged  prostate, 
and  may  serve  as  distinctive  marks  between  the  two 
diseases. 

When  the  pain  is  very  violent,  there  is  often  a 
sense  of  weight  in  the  rectum,  with  a  frequent  de- 
sire to  go  to  stool.  Sometimes  there  are  prolapsus 
ani,  and  piles.  Incontinence  of  urine  is  also  enu- 
merated as  a  symptom.  This  probably  arises  from 
the  relaxation  of  the  sphincter  of  the  bladder,  in 
consequence  of  an  irritation  in  its  general  muscular 
coat.  It  may  also  arise  from  the  stone  being  so  large, 
as  nearly  to  fill  the  whole  cavity  of  the  bladder,  and 
thus  leave  no  room  for  the  accumulation  of  urine, 
which  will  necessarily  be  constantly  passing  off.  I 
have  assisted  in  the  examination  of  a  patient,  who 
died  under  the  latter  circumstances. 

The  urine  is  sometimes  limpid,  commonly  it  has 
a  wheyey  appearance,  probably  from  the  quantity  of 
mucus  it  contains,  and  which  it  deposits  in  the  form 
of  sediment.  This  increased  quantity  of  mucus  is 
secreted,  as  a  defence  to  the  bladder  from  the  irri- 
tation of  the  stone.  After  violent  exercise,  blood 
is  mixed  with  the  urine.  Mucus,  speckled  with 
blood,  is  deemed  an  unequivocal  symptom.  A 
gravelly  deposit  is  also  common :  it  may  be  either 
the  Uric  acid  precipitated  in  the  vessel,  or  a  gravel 
of  the  phosphates. 

When  the  complaint  has  proceeded  to  a  violent 


13 

height,  and  what  may  be  termed  the  latter  stages 
have  set  in,  the  constitution  will  suffer  from  the  irri- 
tation, the  abdominal  muscles  take  on  a  spasmodic 
action,  and  there  will  be  frequent  and  violent  ri- 
gors. 

If  the  stone  be  small  and  have  an  even  surface,  it 
may  cause  the  patient  little  or  no  uneasiness.  And 
whatever  be  the  size,  the  pain  is  not  constant.  It 
returns  occasionally,  making  what  have  been  termed 
fits.  These  are  not  regular  in  their  recurrence,  and 
arise  most  probably  from  the  bladder  being  more 
irritable  at  one  time  than  at  another.  They  have 
been  likewise  attributed  to  the  stone  resting  upon 
the  commencement  of  the  urethra.  A  stone  passing 
from  the  kidney  will  also  cause  a  fit.  Exercise  will 
sometimes  produce  it.  The  roughness  of  a  calculus 
will  also  be  the  cause  of  much  additional  pain.  A 
boy  of  about  14  years  old  had  symptoms  of  stone 
from  his  infancy,  but  of  the  milder  kind.  A  few 
weeks  before  the  operation,  his  pain  became  violent. 
Dr.  Post  extracted  the  stone ;  its  surface  was  smooth, 
except  a  portion  on  which  some  crystals  had  formed; 
these  were  probably  of  a  late  date,  and  gave  rise  to 
the  increase  of  pain. 


CAUSES. 

These,  at  present,  are  involved  in  great  obscurity. 
What  circumstances  give  some  persons  a  disposition 
to  these  concretions,  while  others  remain  exempt, 


14 

have  not  been  satisfactorily  traced.  The  complaint 
seems  occasionally  to  be  hereditary;  in  some  cases 
it  has  been  ascribed  to  the  waters  of  a  particular 
tract  of  country.  But  these  explanations  are  unsatis- 
factory, in  as  much  as  their  application  is  far  from 
general. 

Any  solid  substance  introduced  into  the  bladder,1 
will  form  a  nucleus  for  the  concretion  of  a  stone. 
Cheselden  gives  a  plate  of  a  calculus,  formed  on  a 
bullet  "  shot  through  the  upper  and  back  part  of  the 
thigh  into  the  bladder  of  a  soldier."*  I  have  seen  a 
similar  specimen  in  the  Museum  of  the  Royal  Col- 
lege of  Surgeons,  London.  There  is  said  to  be  one 
of  a  like  kind  in  a  Museum  at  Philadelphia.  Mr. 
Astley  Cooper  exhibits  to  his  class,  a  calculus 
formed  in  the  urethra  of  a  sailor  on  a  piece  of  wood 
which  he  had  introduced  while  at  sea,  as  a  substi- 
tute for  a  bougie.  In  the  above  Museum  in  Lon- 
don, besides  the  specimen  of  bullet  nucleus,  Sir 
Wm.  Blizard,  in  his  lectures  at  the  College,  exhi- 
bited stones  formed  on  bougies,  on  pins,  on  a  bod- 
kin, a  needle,  a  pea,  and  a  hazel-nut.  Le  Dran 
took  a  calculus  from  a  child,  formed  on  a  dossil  of 
lint,  which  had  slipped  into  the  bladder  from  a  former 
operation.f  In  the  Parisian  Journal,  mention  is 
made  of  one  whose  nucleus  was  an  "  ear  of  corn; "J 
and  of  one  extracted  by  Dessault  in  the  Hotel  Dieu, 
whose  nucleus  was  a  "  small  apple." §     And  in 


*  Cheselden's  Anatomy,  edit.  1722,  plate  30. 
j-  Le  Dran's  Operations,  page  250. 

£  The  American  reader  may  be  apprised  that  Indian  corn  is  not  here 
meant. 

£  Vol.  ii.  page  386. 


15 

some  papers,  published  by  the  Massachusetts  Medi- 
cal Society,  in  1790,  a  stone  is  described  to  have 
formed  on  "  two  or  three  inches  of  the  smooth 
stalk  of  a  plant,  broken  off  in  the  bladder  by  acci- 
dent."* It  is  also  familiar  to  surgeons,  that  a  sil- 
ver catheter,  left  for  three  or  four  days  in  the  blad- 
der, has  a  calculous  crust  deposited  on  its  extremity. 

The  consideration  of  these  facts  would  induce  a 
belief  that  calculi  were  generally  deposited  upon  a 
nucleus ;  and  in  the  cases  where  an  external  one  was 
wanting,  a  clot  of  blood,  a  piece  of  hardened  mu- 
cus, a  small  quantity  of  gravel,  and  a  stone  from 
the  kidney,  have  been  assigned ;  they  are  almost  al- 
ways found  in  the  centres  of  calculi. 

The  various  ingredients  which  make  up  the  che- 
mical composition  of  calculi,  are  found  in  the  urine. 
Uric  acid  is  a  permanent  ingredient,  although  "  most 
abundant  in  sick  people  ;"t  the  degree  or  nature  of 
sickness  which  may  produce  it,  is  not  indeed  traced, 
but  it  may  be  owing  to  local  diseased  action,  as  well 
as  to  general  sickness.  The  acid  phosphate  of  lime, 
the  phosphate  of  magnesia,  and  phosphate  of  am- 
monia, are  also  constant  ingredients.  The  oxalate 
of  lime  is  also  found  "as  it  were  by  accident." 
Animal  matter,  that  is,  gelatin  and  albumen,  are 
likewise  always  present;  but  "  very  variable  in  their 
proportions  in  different  kinds  of  urine."  These 
"  afford  the  gluten,  which  holds  the  particles  of  cal- 
culi together." 

Calculi  of  uric  acid,  and  of  oxalate  of  lime,  ap- 
pear to  be  the  only  ones  formed  in  the  kidney,  with- 

*  Page  92. 

f  Thompson's  notes  on  Fourerov's  Chemistry,  vol.  jii.  p.  321- 


16 

out  a  nucleus.  Why  this  should  be  the  situation  of 
the  spontaneous  concretion  of  these  alone,  cannot 
be  well  explained;  unless  we  suppose  that  uric  acid, 
when  abundant,  is  only  mechanically  diffused  in  the 
urine ;  a  supposition  which  derives  support  from  its 
spontaneous  subsidence  after  urine  is  discharged.  If 
such  a  subsidence  took  place  in  the  bladder,  as  the 
particles  would  be  very  small,  they  would  easily  be 
washed  out  in  passing  the  water,  and  the  complaint 
would  remain  in  the  stage  of  gravel  only ;  no  nu- 
cleus being  retained  to  give  rise  to  a  stone.  If  this 
subsidence,  and  consequent  concretion,  should  take 
place  in  the  tubular  part  of  the  kidney,  the  stone 
would  be  there  wedged  in,  and  gradually  receive  ad- 
ditional laminae,  until  it  passed  to  the  bladder. 

The  urine  is  secreted  in  the  bladder  in  a  dilute 
state, — dilute,  comparing  the  proportion  of  water  and 
salts.  This  dilution  is  lessened  by  retention  in  the 
bladder.*  The  salts,  of  course,  may  then  be  more 
readily  deposited;  and  the  presence  of  a  nucleus, 
will  probably  make  this  deposition  invariable.  Crys- 
tallization, perhaps,  results  from  a  still  farther  depri- 
vation of  the  aqueous  parts  of  the  urine. f 

There  are  but  few  data  on  which  to  ground  an 
opinion,  as  to  the  formation  of  mulberry  calculi. 
They  seem  to  be  deposited  in  the  kidney,  but  on 
what  principles  I  cannot  offer  a  conjecture. 

By  adapting  the  above  circumstances  as  may  be 
necessary,  and  by  bearing  in  mind,  that  in  some 

*  Edin.  Syst.  Anat.  vol.  ii.  p.  412.    Haller's  Physiol,  p.  390. 

f  Admitting  that  uric  acid  and  the  phosphates  are  deposited  in  the  raan- 
aer  noticed,  a  difference  between  gravel  and  stone  may  be  assigned.  Gra- 
vel is  the  deposition  of  these  materials,  previous  to  their  having  undergone 
aggregation  or  concretion;  after  this  process  has  begun,  the  disease  is  stone 


17 

oases  the  secretion  of  abundant  uric  acid  may  not 
be  constant,  we  may  account  for  the  different  species 
of  calculi,  whether  of  uric  acid  alone ;  of  that  mixed 
throughout  the  phosphates,  alternating  with  them  in 
layers,  or  forming  a  nucleus  for  them;  or  of  the 
phosphates  alone.  The  animal  operation  which 
yields  the  material,  will  not  indeed  be  accounted 
for ;  but  a  single  step  towards  an  ultimate  explana- 
tion is  not  without  its  value . 


CURE. 

The  first  analysis  of  urinary  calculus  led  to  the 
discovery  of  a  new  acid.  On  the  ground  of  this  dis- 
covery, alkalies  were  used,  in  the  expectation,  that 
passing  by  the  kidneys,  they  might  become  so  far  a 
component  part  of  the  urine,  as  to  dissolve  the  stone. 
In  some  instances  these  proved  beneficial;  but  it 
was  impossible,  that  in  the  greater  number  of  cases, 
they  could  remove  the  concretion.  By  referring  to 
the  table  before  quoted,  it  will  be  seen  that  128  of 
150,  contained  more  or  less  of  the  phosphates,  which, 
as  will  presently  be  noticed,  are  rather  increased 
than  lessened  by  the  exhibition  of  alkalies. 

Mr.  Abernethy,  in  his  lectures,  relates  a  singular 
fact,  much  connected  with  the  present  subject. 
Two  portions  of  calculus  were  put  into  different 
vessels.  Into  one  of  these,  the  urine  of  a  person 
taking  alkali  was  frequently  discharged;  into  the 
other,  urine  from  a  person  not  using  any  medicine. 

3 


18 

The  first  portion  of  calculus  in  a  short  time  crum- 
bled, the  other  remained  firm.  This  experiment 
proves,  that  alkalies  can  enter  the  circulation,  and 
pass  by  the  kidneys ;  or  at  least,  that  they  can  so 
alter  the  urine,  as  to  make  it  capable  of  dissolving  a 
stone.  But  in  this  case,  the  subjects  of  experiment 
were  exposed  to  the  air,  an  agent,  which  may  have 
materially  promoted  the  dissolution  of  the  first. 

Alkalies,  however,  are  known  to  have  a  soothing 
effect  on  the  bladder.  They  are  useful  in  irritation 
of  the  bladder  or  kidneys.  By  this  operation,  they 
have  probably  gained  their  reputation  as  cures  for  the 
stone.  Mr.  Home*  relates  two  cases  of  reputed 
cure  of  this  disease  by  alkalies,  in  one  of  which 
were  found  after  death  20,  and  in  the  other,  14  cal- 
culi. The  symptoms  he  supposed  to  have  ceased 
from  the  confinement  of  these  stones  behind  the  en- 
larged "posterior  lobe  of  the  prostate,"  but  it  is  more 
probable,  that  the  bladder  had  been  rendered  insensi- 
ble to  their  presence,  by  the  remedies  employed. 
The  formation  of  a  cyst  may  also  account  for  some 
cases  of  reputed  cure. 

In  the  opinion  of  Mr.  Brande,  alkalies  may  often 
be  hurtful  in  this  disease,  at  least  they  may  increase 
the  size  of  the  stone.  The  phosphates  are  dis- 
solved in  urine  by  an  excess  of  phosphoric  acid. 
An  alkali,  by  neutralizing  this,  may  increase  the  de- 
position of  these  substances. 

This  opinion  every  practitioner  will  balance  in 
his  own  mind,  with  the  propriety  of  exhibiting  alka- 
lies under  certain  circumstances ;  for  circumstances 
exist,  in  which  they  are  proper.    The  operation  is 

*  Philos.  Trans,  loc.  cit. 


19 

sometimes  unadvisable,  and  the  painful  situation  of 
the  patient  may  call  for  some  assistance.  In  such  a 
case,  as  alkalies  have  proved  at  least  palliative,  they 
certainly  deserve  a  trial.  Caustic  alkali,  with  opium  in 
linseed  decoction,  is  a  very  useful  prescription.  Ef- 
floresced soda  in  pills,  and  soda  water,  are  used ;  but 
are  not  probably  so  efficacious  as  the  former,  as  the 
carbonic  acid  contained  in  them,  having  a  stronger 
affinity  to  the  alkali  than  the  uric  acid,  will  retain  it, 
and  prevent  the  chance  of  a  solution  of  the  stone  by 
its  uric  acid  uniting  with  the  alkali.  The  dose  of 
alkali  is  in  no  case  to  be  large. 

With  the  alkaline  remedies,  may  be  noticed  lime- 
water.  Its  solvent  powers  are  analogous  to  those  of 
alkalies :  how  far  it  may  prove  soothing,  I  have  no 
authority  to  determine. 

Messrs.  Fourcroy  and  Vauquelin  have  lately  re- 
vived attempts  to  dissolve  a  stone  by  injecting  alka- 
lies into  the  bladder.  They  have  found  occasional 
success.  But  in  addition  to  the  objections  to  alkalies 
in  general,  this  plan  is  imperfect,  from  the  dilute 
state  in  which  the  medicine  must  be  introduced, 
and  the  indisposition  of  the  bladder  to  bear  artificial 
distention.  It  is  probable  too,  that  the  success  has 
been  very  limited,  or  the  method  would  now  have 
more  numerous  advocates,  as  their  experiments  were 
instituted  several  years  since. 

As  the  phosphate  calculi  are  soluble  in  muriatic 
acid,  this  has  been  exhibited  as  a  remedy.  It  is  ad- 
mitted by  Mr.  Brande,  that  it  possesses  efficacy,  so 
far  as  the  phosphate  materials  of  a  calculus  are  con- 
cerned. But  if  the  stone  be  made  up  in  part  of  uric 
acid,  or  if  its  nucleus  be  of  that  substance,  we  only 
lose  time  in  the  experiment.    The  patient  will  de- 


20 

rive  but  limited  benefit  from  a  partial  cure,  and  the 
operation  will  be  as  necessary  after  a  course  of  acid, 
as  before.  A  reference  to  the  table  will  show,  that 
uric  acid  is  an  ingredient  too  frequently  met  with, 
to  warrant  an  expectation  of  success.  Similar 
objections  exist  to  the  injection  of  this,  as  were 
noticed  of  alkalies. 

To  the  practical  surgeon,  however,  it  is  needless 
to  multiply  proofs  of  the  inefficacy  of  cures  for  stone.* 
An  operation  becomes  in  almost  every  case  neces- 
sary. And  if  a  patient's  situation  does  not  forbid, 
it  is  improper  to  defer  it,  lest  the  kidneys  become  so 
diseased  as  to  render  it  of  no  avail. 

Old  age  does  not  appear  to  be  an  objection  to  ope- 
rating. Patients  above  80  have  been  successfully 
cut,  between  60  and  70  frequently,  and  at  60  very 
frequently.  It  is  not  well  to  operate  on  a  very  young- 
child,  as  untoward  occurrences  during  the  operation 
are  more  seriously  felt  The  youngest  child  on 
whom  I  have  heard  of  its  being  performed  with  suc- 
cess, was  a  year  and  nine  months  old. 

The  existence  of  another  disease  in  the  system 
may  forbid  an  operation.  To  add  a  new  disturbance 
to  a  constitution  in  such  a  state,  would  be  a  great 
hazard  of  life.  The  other  disease  should  be  re- 
moved, and  then  the  operation  may  be  safely  under- 
taken. 

If  there  be  pain  in  the  loins,  and  other  symptoms 
of  a  descending  calculus,  it  is  proper  to  wait  until 

*  In  a  preceding  note,  a  distinction  was  pointed  out  between  gravel  and 
stone.  From  that  it  will  appear,  that  the  former  of  these  will  only  be 
known  by  observing  the  gravelly  discharge.  If  the  complaint  be  in  this 
state  without  symptoms  of  stone,  the  exhibition  of  alkalies  or  muriatic  acid 
may  be  useful. 


21 

these  have  subsided,  that  the  additional  calculus 
may  be  removed  by  the  same  operation. 

A  discharge  of  blood  on  introducing  the  sound, 
and  other  symptoms  of  highly  irritable  bladder,  may 
render  it  prudent  to  wait,  until,  by  the  exhibition  of 
alkalies  and  other  remedies,  the  excessive  irritability 
be  subdued.  A  slight  degree  of  irritability  is  no 
objection  to  operating. 


SOUNDING. 

No  single  symptom  of  stone  is  sufficiently  une- 
quivocal to  warrant  an  operation.  Nay,  although 
the  whole  united  may  afford  the  highest  presump- 
tive proof  of  the  existence  of  a  calculus,  no  surgeon 
is  justified  in  operating,  unless  he  receive  the  more 
full  conviction  to  be  obtained  from  sounding. 

Previous  to  introducing  the  sound,  the  urine  should 
have  been  retained  a  few  hours,  that  the  bladder  may 
be  sufficiently  distended  to  allow  the  necessary  mo- 
tion of  the  instrument. 

The  most  convenient  position  is  a  recumbent  one, 
with  the  head  and  chest  elevated.  The  hip  and  knee 
joints  are  to  be  flexed,  the  knees  are  to  remain  asun- 
der, and  the  patient  must  allow  his  muscles  to  be  as 
relaxed  as  possible.  Other  positions  may  be  neces- 
sary, but  these  must  be  regulated  by  circumstances. 

The  introduction  of  a  sound,  if  there  be  no  dis- 
ease, is  effected  without  much  difficulty.  The  canal 
of  the  urethra  is  to  be  followed;  and  if  the  point  of 


22 

the  instrument  be  entangled  in  the  folds  of  its  lining 
membrane,  or  in  the  orifices  of  the  lacunas,  it  must 
be  slightly  withdrawn,  and  the  attempt  repeated.  A 
large  sound,  in  a  healthy  urethra,  is  most  easily  in- 
troduced. 

Some  have  disputed  whether  a  sound  should  be 
passed  with  its  convex  or  concave  side  to  the  abdo- 
men. The  former  requires  a  turn  when  the  point 
reaches  the  membranous  part  of  the  urethra.  This 
turn  is  supposed  to  increase  very  much  the  pain  of 
introduction — a  pain  so  great  in  some  cases,  that  I 
heard  a  boy,  who  had  been  twice  before  cut,  while 
on  the  table  for  a  third  operation,  entreat  the  surgeon 
not  to  introduce  the  staff,  as  he  feared  it  more  than 
the  incisions  themselves.  I  have  inquired  of  pa- 
tients, in  whom  I  introduced  the  catheter  both  ways, 
and  they  found  no  perceptible  difference.  From 
this  fact,  and  from  finding  surgeons  divided  in 
opinion,  it  is  probable  that  there  is  no  very  great  dif- 
ference between  the  two  methods.  Introducing  it 
with  the  convex  part  to  the  abdomen,  appears  rather 
the  easiest  to  the  surgeon. 

Stricture  may  prevent  the  passage  of  a  sound.  If 
this  be  spasmodic,  a  gentle  pressure  against  the  ob- 
struction will  often  make  it  dilate.  If  the  stricture 
be  permanent,  its  cure  is  to  be  first  effected. 

Enlargement  of  the  prostate  will  change  the  curve 
pf  the  urethra,  giving  it  a  turn  upwards.  When  the 
sound  is  checked  at  this  part,  a  finger  should  be  in- 
troduced into  the  rectum  to  raise  its  point. 

The  stone  is  often  felt  immediately  on  the  enter- 
ing of  the  sound.  Sometimes  it  is  lodged  in  the  in- 
ferior posterior  part  of  the  bladder,  so  as  to  require 
a  finger  in  the  rectum,  to  elevate  it  until  it  strikes 


23 

the  instrument.  The  patient's  position  may  be  va- 
ried. Or  a  catheter  may  be  introduced  in  place  of 
the  sound,  which,  as  it  allows  the  urine  to  flow,  will 
make  the  bladder  contract  so  as  to  bring  the  stone  in 
contact  with  it.  Mr.  J.  Bell*  is  very  strenuous  in 
advising*  the  introduction  of  a  finger  or  two  into  the 
anus,  to  ascertain  the  relative  situation  of  parts,  and 
the  size  of  the  stone.  But  I  think,  that  a  surgeon 
should  rely  with  caution  on  information  so  indis- 
tinctly obtained. 

Mr.  Abemethy  relates  in  his  lectures,  that  a  pa- 
tient was  obliged  to  introduce  a  catheter  eveiy  two 
hours  for  several  years,  to  discharge  his  urine ;  but 
never  discovered  any  stone.  Seven  were  found  in 
his  bladder  after  death. 

Dessaultf  records  a  case,  in  which  the  operation 
was  performed  after  (as  the  surgeon  and  his  assist- 
ants thought)  having  felt  and  heard  the  stone  by  the 
sound.  When  the  forceps  were  introduced,  they 
could  not  be  opened  to  grasp  the  stone.  A  scoop 
was  passed  in  to  assist  the  extraction,  and  made  the 
noise  of  two  hard  bodies  in  collision ;  but  no  stone 
was  extracted.  On  examination,  "  no  stone  was 
found  to  exist ;  but  the  bladder  was  found  compact, 
cartilaginous  in  its  circumference." — It  is  reported 
of  Mr.  Cheselden,  "  that  in  the  course  of  his  prac- 
tice, which  indeed  was  very  extensive,  three  patients 
were  cut  by  him  in  whom  no  stones  were  discovered, 
and  where  a  schirrous  or  hardened  state  of  the  blad- 
der had  given  rise  to  the  mistake.":!;    These  cases 


*  Smith's  Abridgement,  page  174. 

f  Parisian  Journal,  vol.  ii.  p.  125. 

4  R.  Bell's  Surgery,  vol.  iii.  p.  164.    Troy  edit. 


24 

cannot  render  the  feel  of  a  stone  in  sounding  a  less 
reasonable  ground  for  operating. 

It  must  be  held  as  an  invariable  maxim,  never  to 
operate  unless  the  stone  be  felt  by  the  staff,  when 
introduced  for  the  operation.  Cases  have  occurred, 
in  which  the  stone  has  slipped  between  the  fasciculi 
of  the  muscular  coat  of  the  bladder,  and  carrying 
with  it  the  internal  membrane,  has  formed  a  sac,  se- 
parate from  the  general  cavity  of  that  viscus.  Mr. 
Home,  in  the  paper  above  quoted,  states  that  he  has 
frequently  met  with  them,  even  two,  three,  or  four 
in  one  bladder,  and  each  containing  a  stone.  Dr. 
Smith,  in  his  notes  on  J.  Bell's  Surgery,  mentions 
that  he  has  seen  one.*  In  Mr.  Abernethy's  collec- 
tion, I  have  seen  such  specimens.  When  in  such  a 
sac,  a  stone  is  not  painful;  and  as  the  sac  may  be 
formed  between  the  times  of  first  sounding  and  of 
operating,  it  would  be  unjustifiable  to  hazard  the  pa- 
tient's life,  for  the  removal  of  a  disease  which  was 
to  be  no  longer  troublesome.  These  sacs  have 
sometimes  prevented  the  extraction  of  a  stone  after 
an  operation  for  that  purpose.  Dr,  W.  Moore  re- 
lated to  me  an  instance  of  this,  which  occurred  to 
the  late  Dr.  J.  Jones  of  this  city.  The  nature  of 
the  case,  and  the  existence  of  the  sac,  were  made 
evident  by  examination.  An  operation  similarly  un- 
successful occurred  lately  in  this  place.  An  ex- 
amination of  the  patient  could  not  be  procured;  but 
as  it  was  a  child,  the  not  finding  the  stone  arose  more 
probably  from  its  being  in  a  sac,  than  from  a  disease 
of  the  bladder  resembling  that  in  Dessault's  and 
Cheselden's  cases.     These  are  cases  which  ought 

*  Paare  187 


25 

not  to  prevent  us  from  deeming  the  sound  a  sufficient 
test  of  the  propriety  of  an  operation,  as  the  circum- 
stances, from  their  nature,  are  not  within  the  know- 
ledge or  control  of  the  surgeon,  and  as  we  know  of 
no  test  equal  in  certainty  to  this  instrument. 


ANATOMY  OF  THE  PARTS  CONCERNED 
IN  THE  OPERATION. 

In  lithotomy,  as  in  all  other  operations,  an  accu- 
rate acquaintance  with  the  parts  through  which  in- 
cisions are  to  be  made,  is  absolutely  necessary.  A 
moderate  share  of  anatomical  knowledge  has  indeed 
sufficed  for  some  operators.  Thus  Frere  Jacques  is 
said  to  have  performed  the  operation,  "  without  any 
direction  and  without  any  knowledge  of  the  parts  he 
was  to  cut;"  his  patients  "  were  found  with  the  blad- 
der cut  through,  guts  wounded,"  &c. — The  only 
means  of  giving  a  humane  operator  confidence,  is  a 
perfect  "  knowledge  of  the  parts  he  is  to  cut." 

It  will  be  readily  seen,  that  mere  description  of 
the  anatomy  of  these  parts,  will  not  convey  an  ade- 
quate idea  of  them.    Dissection  alone  can  do  this. 

A  point  in  the  perineum,  just  below  the  bulb  of 
the. urethra,  is  to  be  considered  the  centre.  From 
this,  the  transversi  perinei,  accelerator  urinse,  and 
sphincter  ani  muscles  proceed.  The  transversi  pe- 
rinei are  reckoned  two ;  they  are  given  off  laterally 
from  this  point,  and  are  inserted  into  the  tuber  ischii. 
The  accelerator  urin<e  sends  its  fibres  diverging  up- 

4 


26 

wards;  and  the  sphincter  ani  goes  diverging  down- 
wards. The  erector  penis  arises  from  the  tuber 
ischii,  and  runs  upwards  and  slightly  inwards  upon 
the  crus  of  the  penis. 

The  bulb  of  the  urethra  is  just  before  a  perpen- 
dicular let  fall  from  the  arch  of  the  pubis*  Directly 
behind  it  is  the  membranous  part  of  that  canal. 
Mr.  Wilson,  a  teacher  of  anatomy  in  London,  has 
described  two  muscles  "of  a  triangular  shape,  united 
below  by  a  common  tendon,  but  having  each  a  sepa- 
rate tendinous  attachment  to  the  symphisis  pubis,  and 
which  are  so  placed  as  to  surround  the  membranous 
part  of  the  urethra."*  After  leaving  these  muscles, 
the  canal  enters  the  prostate  gland,  being  completely 
surrounded  by  it.  Here  it  is  called  neck  of  the  blad- 
der. While  leaving  the  prostate,  it  receives  an  in- 
distinct sphincter  of  muscular  fibres  from  the  gene- 
ral coat  of  the  bladder;  it  then  opens  into  that 
cavity. 

The  rectum  lies  close  behind  the  bladder,  con- 
nected with  it  at  the  inferior  part  by  a  loose  cellular 
and  ligamentous  substance.  This,  at  its  lower  end, 
is  supported  by  the  levator  ani  muscle ;  which  also 
surrounds  the  neck  of  the  bladder,  prostate  gland, 
&c.  and  lies  at  its  anterior  edge,  in  contact  with  Mr» 
Wilson's  muscle. 

The  vesiculas  seminales  lie  between  the  bladder 
and  rectum.  They  proceed  from  the  posterior  part 
of  the  prostate,  in  a  diverging  manner,  backwards. 
The  vasa  deferentia  lie  within  them.  The  cut  of 
lithotomy  is  made  anterior  to  these,  sufficiently  s® 


*  Medico-Chirurg.  Transact,  p.  176, 


27 

to  avoid  their  ducts,  which  empty  at  the  lower  sur- 
face of  the  neck  of  the  bladder. 

Three  arteries  may  be  enumerated  as  concerned 
in  lithotomy,  the  internal  pudendal,  the  artery  of 
the  bulb,  and  the  transverse  perineal.  The  former 
of  these  runs  along  the  ramus  of  the  ischium,  exte- 
rior to  the  levator  ani  muscle,  and  rather  within  the 
edge  of  the  ramus.  It  gives  off  the  transverse  peri- 
neal, which  follows  the  transversus  perinei  muscle. 
At  the  root  of  the  penis  it  gives  off  the  artery  of 
the  bulb,  and  is  then  lost  in  the  dorsal  and  central 
arteries  of  the  penis. 

The  parts  cut  through  in  the  lateral  operation,  are 
these:  1.  The  common  integuments  and  cellular 
membrane ;  2.  The  transverse  perineal  muscles  and 
artery;  3.  The  membranous  part  of  the  urethra,  with 
Mr.  Wilson's  muscle  investing  it;  4.  The  neck  of 
the  bladder,  and  a  side  of  the  prostate;  5.  The 
sphincter  of  the  bladder,  and  a  small  portion  of  its 
parietes. 

This  enumeration  of  parts  cut  through,  is  given 
on  the  supposition  that  we  direct  our  incision,  first 
to  the  fore  part  of  the  prostate,  and  next  to  the  mem- 
branous urethra.  But  the  more  ordinary  course  is 
to  the  bulb  of  the  urethra;  in  which  case,  that  part, 
its  artery,  and  perhaps  a  small  portion  of  the  accele- 
rator urinae,  are  divided  in  addition  to  the  parts 
just  mentioned.  There  is  no  farther  impropriety  in 
this,  than  that  the  operation  is  not  so  neat,  and  that 
an  additional  artery  is  divided. 

The  internal  pudendal  artery  is  not  divided  unless 
it  vary  its  situation,  lying  nearer  the  centre  of  the 
perineum,  or  the  incision  reach  very  far  to  one  side. 
It  is  frequently  cut  by  Mr.  Cline's  gorget. 


28 

The  operator  cannot  expect  to  see  all  the  parts 
through  which  he  cuts.  The  blood  from  the  vessels 
of  the  integuments  will  probably  conceal  them : 
when  the  transverse  perineal  artery  is  divided,  they 
will  certainly  be  hid.  An  accurate  anatomy  will 
now  be  especially  useful.  The  finger  must  be  the 
guide;  "it  is  only  by  feeling  opposition  and  stric- 
ture that  we  recognize  the  transverse  muscle;"  and 
the  chief  direction  for  finding  the  membranous  part 
of  the  urethra,  is  the  groove  of  the  staff. 

The  axis  of  the  pelvis  is  a  line  drawn  from  the 
extremity  of  the  os  coccygis  to  the  umbilicus.  The 
axis  of  the  bladder  is  a  parallel  line,  which,  for  prac- 
tical purposes,  is  to  be  considered  as  beginning  at 
the  commencement  of  the  urethra.  This  imaginary 
line,  it  is  of  the  highest  importance  to  remember,  as 
it  is  the  direction  in  which  the  instrument  is  entered 
for  making  the  second  incision.  Either  from  igno- 
rance of  this  anatomical  point,  or  from  neglecting  it 
in  practice,  have  arisen  most  of  the  accidents  of  the 
operation. 


OPERATION. 

It  would  swell  this  thesis  uselessly  to  recapitulate 
the  different  methods  which  have  been  proposed  for 
extracting  a  calculus  from  the  bladder.  Nay,  it 
would  require  a  search  of  no  small  extent,  to  dis- 
cover the  whole.  Some  have  become  obsolete  from 
not  bearing  the  test  of  experiment,  and  some  have 


29 

rested  in  the  undisturbed  narratives  of  their  inven- 
tors. The  only  method  now  used  is  the  lateral  ope- 
ration. This  in  the  first  incision  is  the  same  in  all 
cases — the  second  incision  varies,  as  it  is  made  by  a 
gorget  or  bistoury.* 

The  patient  is  to  be  prepared  for  the  operation  by 
reducing  his  habit,  if  it  be  plethoric,  by  low  diet 
and  an  occasional  purge.  If  he  be  already  debili- 
tated, he  is  to  be  restored  by  generous  diet.  The 
occasional  introduction  of  the  sound,  to  accustom 
the  urethra  and  bladder  to  its  irritation,  is  re- 
commended by  Mr.  Astley  Cooper  in  his  lectures. 
Previous  to  operating,  the  rectum  is  to  be  emptied 
by  an  enema  or  gentle  cathartic,  to  allow  it  to  be  as 
little  distended,  and  consequently  as  distant  from  in- 
jury as  possible.  The  urine  should,  as  in  sounding, 
be  retained  for  a  few  hours. 

The  hands  are  to  grasp  the  soles  of  the  feet,  and 
the  patient  is  to  be  bound  in  that  position.  Some 
use  an  additional  bandage,  passing  from  the  neck 

*  I  ought,  perhaps,  to  apologize  for  omitting  the  variety  of  the  lateral  ope- 
ration invented  by  Mr.  Cheseklen,  and  sanctioned  by  Mr.  J.  Bell.  It  con- 
sists in  continuing  the  external  incision,  until  the  scalpel  divides  the  "  sides 
cf  the  bladder,  immediately  above  the  prostate,"  and  in  drawing  it  "  firmly 
and  steadily  towards  him  (the  surgeon),  pressing  the  knife  into  the  groove 
of  the  staff,"  till  "  the  gland  and  cervix  vesica?  are  divided."  This  operation 
one  would  be  led  to  imagine  the  best,  as  it  has  received  the  approbation  of 
such  eminent  surgeons;  but  those  less  renowned  do  not  seem  to  favour  it, 
and  Cheselden  himself  abandoned  it  for  the  gorget  in  his  third  manner  of 
operating.  It  certainly  is  more  complicated,  and  leaves  a  more  ragged 
wound;  and  if  the  bistoury  proposed  should  not  be  liable  to  the  objections  to 
the  gorget,  none,  I  trust,  will  question  that  the  incision  from  the  centre  of 
the  perineum,  is  preferable  to  that  towards  it.  For  accounts  of  this  opera- 
tion, the  reader  is  referred  to  the  papers  relative  to  Mr.  Cheselden's  me- 
thods, collected  and  republished  by  Dr.  Thompson  of  Edinburgh;  to  Coo- 
per's First  Lines  of  Surgery;  and  Smith's  Abridgement  of  J.  Bell's  Surgery, 
page  181. 


30 

under  the  knees,  to  limit  still  farther  the  struggling. 
The  patient's  buttocks  are  to  be  brought  just  over 
the  edge  of  the  table,  the  knees  kept  asunder,  and 
the  body  supported  by  assistants;  the  perineum  is 
to  be  exposed  to  a  good  light,  and  shaved  if  neces- 
sary. The  staff  is  to  be  introduced  by  the  surgeon, 
and  given  to  an  assistant,  who  holds  it  firmly  with 
the  curve  of  it  pressing  gently  outwards  the  left  side 
of  the  raphe,  just  below  the  scrotum.  With  his 
other  hand  the  assistant  supports  the  scrotum. 

As  the  operation  is  usually  performed,  the  inci- 
sions are  made  by  two  instruments.  This  makes  a 
natural  division  of  the  operation  into  two  incisions, 
the  first  or  external,  and  the  second  or  internal  inci- 
sion. 

The  operation  is  begun,  by  entering  a  scalpel  near 
an  inch  behind  the  scrotum,  on  the  left  side  of  the 
raphe,  over  the  part  where  the  staff  is  felt;  this  inci- 
sion is  to  be  carried  in  a  direct  line  till  it  be  an  inch 
past  the  anus,  midway  between  that  and  the  tuber 
ischii.  The  cellular  and  ligamentous  substance, 
with  the  transverse  muscles,  are  to  be  divided  by  a 
continuance  of  the  incision,  directed  towards  the 
prostate,  with  the  rectum  kept  out  of  the  way  by 
such  of  the  surgeon's  fingers  as  are  not  otherwise 
employed.  The  bulb  of  the  urethra  is  to  be  avoided, 
and  when  the  finger  can  distinguish  the  groove  of 
the  staff  so  plainly  as  to  be  certain  that  the  mem- 
branous urethra  only  is  between  them,  this  is  to  be 
divided  upon  the  staff:  it  is  to  be  divided  by  one 
bold  stroke;  a  repetition  of  cuts  will  endanger  a 
loss  of  substance,  and  according  to  Mr.  J.  Bell,* 

*  Smith's  Abi-idgement,  page  1&6. 


31 

may  contribute  to  the  forcing  "  off  the  neck  of  the 
bladder  and  prostate  from  the  urethra"  by  the  gor- 
get. The  cut  into  the  membranous  part  of  the  ure- 
thra terminates  the  first  or  external  incision. 

The  second  incision  is  done  in  two  ways.  1.  An 
instrument  is  thrust  in,  which  makes  its  incision  in 
entering.  2.  A  bistoury  is  introduced,  in  withdraw- 
ing which,  an  incision  is  made,  regulated  in  size  by 
the  judgment  of  the  operator. 

The  most  used  instrument  of  the  former  class 
is  the  gorget.  This  is  to  be  fitted  into  the  groove 
of  the  staff,  and  thrust  along  it  to  the  bladder, 
in  the  direction  of  its  axis,  until  the  flow  of  urine 
assures  us  that  it  has  entered  that  viscus.  The  staff 
is  then  usually  withdrawn,  the  forceps  introduced  on 
the  gorget  as  a  director,  and  the  latter  instrument 
also  removed.  The  stone  is  then  felt  for,  and  ex- 
tracted. The  gorget  is  of  various  forms.  As  in- 
struments on  the  same  principle,  may  be  reckoned, 
the  scalpel  as  spoken  of  by  Sharpe,*  and  used  by 
Mr.  C.  Bell,  and  the  beaked  scalpel  as  formerly 
used  by  Mr.  A.  Cooper.  When  either  of  the  latter 
instruments  is  used,  the  staff  is  to  remain  in,  the 
scalpel  to  be  immediately  withdrawn,  and  the  finger 
introduced  upon  the  staff,  both  to  ascertain  the  place 
and  size  of  the  stone,  and  to  serve  as  a  director  for 
the  forceps.  This  practice  indeed  is  preferable  in 
using  the  gorget;  it  lessens  the  risk  of  cutting- 
through  the  sides  of  the  bladder.  It  was  introduced 
formerly  in  the  London  Hospital  by  Mr.  Thomas 
Blizard;  and  as  the  gorget  was  no  longer  to  serve  as 
director  to  the  forceps,  he  had'  it  made  with  its  han- 

*  Operat.  Surg.  p.  96,  edit  1782.. 


32 

die  continued  in  a  line  with  the  blade.    This  direc- 
tion gave  the  instrument  obvious  advantages. 

Of  the  second  description  of  instruments,  those 
of  Mr.  Astley  Cooper,  and  Mr.  Thomas  Blizard, 
appear  the  most  perfect  in  principle.  That  of  the 
former  is  a  curved  bistoury,  with  a  beak  projecting 
from  its  point.  That  of  the  latter  is  a  straight  bis- 
toury, rounded  for  three  fourths  of  an  inch  from  its 
point,  with  a  beak  slightly  turned  up  to  be  more 
readily  fitted  into  the  groove  of  the  staff.*  The  in- 
cision by  these  instruments  is  made,  as  was  stated, 
in  withdrawing  them.  The  finger  is  then  to  be  in- 
troduced upon  the  staff,  and  that  instrument  with- 
drawn ;  the  situation,  and,  if  possible,  the  size  of  the 
stone  are  to  be  ascertained  by  the  finger;  the  for- 
ceps is  to  be  introduced  under  its  guidance,  and  the 
stone  grasped.  A  minute  point,  but  one  of  some 
importance,  should  next  be  attended  to;  the  forceps 
is  to  be  turned,  that  the  surgeon  may  be  certain  that 
no  fold  of  the  bladder  is  entangled  in  its  grasp. 
This  ascertained,  the  stone  is  to  be  extracted  by  a 
continued  force,  united  with  a  motion  of  the  han- 
dles of  the  forceps  upwards  and  downwards,  consi- 
dering that  instrument  as  "  two  levers."  When  the 
stone  is  taken  away,  a  finger  is  to  search  the  blad- 
der lest  there  be  more. 

If  the  wound  in  the  bladder  be  not  large  enough 
to  extract  the  stone,  it  must  be  dilated  by  a  probe- 
pointed  bistoury.  If  an  extensive  incision  be  re- 
quired, the  opposite  side  of  the  bladder  is  to  be  cut 

*  The  plate  at  the  title  page  represents  this  instrument.  One  view 
shows  the  form  of  the  Made  and  the  rounding  of  it  towards  the  point.  The 
other  shows  the  elevation  of  the  beak.  The  handle  should  be  made  rough 
for  a  more  secure  grasp.    The  figure  is  of  the  exact  size  of  the  instrument. 


33 

with  the  same  instrument.  If  the  stone  be  too  large 
to  extract  whole,  it  should  be  broken.  To  this 
practice  we  are  led  by  a  comparison  of  chances  of 
the  patient's  recovery,  rather  than  by  a  grounded 
hope  of  such  an  event. 

Calculi  sometimes  adhere  to  the  bladder,  i.  e. 
a  fungus  shoots  from  the  internal  surface  of  that 
viscus,  which  fixes  upon  the  stone.  It  may  ab- 
sorb portions  of  it,  and  enter  the  crevices  thus 
made.  There  can  be  no  hesitation  as  to  the  pro- 
priety of  removing  the  stone,  if  possible.  Death  is 
certain  if  it  be  left;  at  least  it  will  be  so  if  an  un- 
successful effort  has  been  made  with  the  forceps. 
Vigilance  to  prevent  abdominal  and  vesical  inflamma- 
tion, after  such  a  calculus  is  taken  away,  may  afford 
the  patient  a  chance  of  recovery. 

After  extracting  the  stone,  the  surgeon  is  to  attend 
to  the  haemorrhage.  If  this  be  trifling,  we  may  con- 
clude that  no  vessel  likely  to  cause  danger  has  been 
cut.  If  bleeding  arteries  be  at  all  conspicuous,  they 
ought,  if  possible,  to  be  tied.  If  this  cannot  be  done, 
and  the  haemorrhage  be  troublesome,  pressure  should 
be  made.  This  would  be  best  done  by  the  finger  of 
an  assistant;  but  as  it  must  be  continued  some  days, 
and  as  a  change  of  assistants  will  endanger  a  renewal 
of  haemorrhage,  the  use  of  a  canula  will  be  found  an 
eligible  substitute.  This  is  much  dwelt  upon  by  Le 
Dran,  and  I  have  seen  it  used  successfully  by  Dr. 
Post. 

The  dressing  of  the  wound  is  a  matter  of  minor 
importance.  Little  difference  in  the  cure  takes 
place  whether  it  be  dressed  or  not.  The  scrotum 
should  be  supported,  particularly  if  a  canula  is 
used.     The  patient's  stomach  is  liable  to  be  out  of 

5 


34 

order  by  his  complicated  sufferings.  Mr.  Abemethy 
is  particular  in  directing  the  attention  of  his  class  to 
this.  He  recommends  the  occasional  exhibition  of 
a  few  grains  of  the  pil.  hydrarg.  and  of  a  gentle  purge. 
The  latter  will  be  particularly  serviceable,  if  lying 
in  bed  render  the  patient  costive. 

"  The  first  good  symptom  after  the  operation, 
is  the  urine  coming  freely  away,  as  we  then  know 
the  lips  of  the  bladder  and  prostate  are  not  much 
inflamed,  for  they  often  grow  turgid,  and  shut 
up  the  orifice  in  such  a  manner,  as  not  only  to 
prevent  the  issue  of  the  water,  but  even  the  in- 
troduction of  the  finger  or  female  catheter,  so  that 
sometimes  we  are  forced  to  pass  a  catheter  by 
the  penis.  From  this  symptom  too,  we  learn 
that  the  kidneys  are  not  so  affected  by  the  opera- 
tion as  to  cease  doing  their  office;  which,  though 
a  very  rare  circumstance,  may  possibly  occur."* 
The  urine  coming  freely  away,  is  also  a  proof  that 
clots  have  not  formed  in  the  bladder*  This  cavity 
is  sometimes  a  reservoir  for  the  haemorrhage,  and 
the  blood  will  entangle  a  considerable  quantity  of 
urine  with  it  in  coagulating.  It  is  this  entangling  of 
the  urine  which  makes  the  clots  so  large,  rather  than 
blood  "  collected  in  great  quantities  in  the  cavity  of 
the  bladder."  The  existence  of  these  clots  is 
known  by  a  want  of  a  "  free  discharge  of  urine," 
and  when  large,  they  occasion  pain  and  swelling  of 
the  abdomen,  and  fever.  As  soon  as  their  existence 
is  suspected,  the  surgeon  should  introduce  his  fin- 
ger, break  them  down,  and  procure  a  complete 
evacuation  of  them.     As  a  preventive,  the  patient 

*  Sharpe's  Opex'atioas,  page  99. 


35 

should  lie  with  the  wound  rather  depending,  that  aii 
effused  blood  may  pass  outwardly. 

Peritoneal  inflammation  is  a  very  frequent  cause 
of  a  fatal  event  after  lithotomy.  This  is  known  by 
the  frequent  and  rapid  pulse,  and  the  tenderness  over 
the  abdomen.  As  soon  as  these  symptoms  appear, 
both  local  and  general  blood-letting  are  to  be  largely 
employed.  The  warm  bath  is  an  essential ;  fomen- 
tations are  to  be  made  externally,  and  internally  by 
clysters.  The  bowels  are  to  be  kept  open  by  full 
doses  of  the  ol.  riciru  com. 

A  violent  and  fatal  constitutional  irritation  some- 
times takes  place  after  lithotomy.  Mr.  T.  Blizard 
related  to  me  several  cases  of  this  kind:  he  recom- 
mends a  large  opiate  to  be  invariably  given,  as  the 
irritation  is  more  certainly  fatal  than  that  occurring 
after  any  other  operation.  The  opiate  is  indeed  the 
usual  prescription  immediately  after  every  capital 
operation,  but  the  considerations  noticed  should 
make  it  a  constant  one  after  lithotomy. 

The  bladder  is  frequently  more  or  less  irritable 
previous  to  operating.  If  this  should  continue  or 
increase  afterwards,  opiate  clysters  are  to  be  resorted 
to.  This  occurrence  is  chiefly  in  old  patients,  and 
is  not  easily  subdued  by  any  remedies. 

When  there  is  no  untoward  occurrence,  the  urine 
commonly  passes  through  the  wound  for  a  fortnight, 
three  weeks,  or  a  month.  At  the  expiration  of  this 
time,  it  is  in  most  cases  healed.  Sometimes  the 
separating  of  sloughs  will  protract  the  cure;  and 
occasionally  the  passage  continues  fistulous. 

Calculi  seldom  form  after  an  operation ;  the  nu- 
cleus is  taken  away,  and  the  patient  may  escape  a 
second.    All,  however,  are  not  so  fortunate.    A  case 


36 

was  before  mentioned  of  a  boy  operated  on  the  third 
time.  At  this  last  operation,  two  stones  were  taken 
from  the  perineum,  and  one  from  the  commence- 
ment of  the  urethra.  The  latter  had  taken  on  the 
form  of  that  canal.  Those  in  the  perineum  got 
there  probably  from  the  bladder,  or  may  have  been 
deposited  from  the  urine,  as  it  passed  that  situation 
through  sinuses  consequent  to  the  former  operations. 
This  was  performed  by  Mr.  Astley  Cooper.  In 
cases  like  this,  it  may  sometimes  be  proper  to  cut 
on  the  right  side  of  the  perineum. 


CIRCUMSTANCES  OF  PECULIARITY  IN 
THE  FEMALE. 

The  operation  of  lithotomy  is  less  frequently  ne- 
cessary in  the  female  than  in  the  male.  The  ure- 
thra is  shorter,  larger,  and  more  dilatable.  Con- 
sequently stones  of  considerable  magnitude  will 
occasionally  pass. 

In  the  Medico- Chirurgical  Transactions,*  a  very 
instructive  case  of  artificial  distention  of  the  female 
urethra  is  related  by  Mr.  Thomas.  His  patient 
had  laboured  under  retention  of  urine,  and  as  no 
regular  assistance  was  at  hand,  had  "  an  ivory  ear- 
picker"  introduced.  This  let  off  a  part  of  the  wa- 
ter, but  unfortunately  slipt  in.  From  an  unwilling- 
ness to  have  an  incision  made,  Mr.  T.  was  induced 

*  Page  123. 


37 

to  use  the  sponge  tent  to  dilate  the  passage.  This 
he  in  the  end  effected ;  he  introduced  his  fore-finger, 
and  extracted  the  ear-picker.  He  adds,  "  I  believe, 
had  the  case  required  it,  both  thumb  and  finger 
would  have  passed  into  the  bladder  without  the 
smallest  difficulty." 

Mr.  Thomas  quotes  other  similar  cases — one  in 
particular,  from  the  Philosophical  Transactions,  of 
a  stone  voided  by  a  woman,  "  the  circumference  of 
which  measured  the  longest  way  7-^  inches,  and 
round  about  where  it  was  thickest  5f  inches,  its 
weight  near  2i  ounces  troy." 

These  facts  sufficiently  explain  why  females  less 
frequently  become  subjects  of  this  operation. 

In  addition  to  the  symptoms  enumerated  as  occur- 
ring in  the  male,  there  will  be  a  bearing  down  of  the 
uterus,  and  excessive  pain  at  the  meatus  urinarius. 
But  in  the  female,  as  in  the  male,  the  surgeon  is  to 
trust  only  to  the  actual  feeling  of  the  stone.  He 
should  also  be  particular  that  he  introduce  the  sound 
himself.  Cases  have  occurred  where,  from  regard 
to  false  delicacy,  a  surgeon  has  permitted  his  patient 
to  introduce  it,  and  he  has  been  deceived  when  feel- 
ing the  grating  sensation,  by  the  sound  rubbing  upon 
a  pebble,  or  other  extraneous  substance,  introduced 
into  the  vagina. 

The  operation  in  the  female  is  particularly  simple ; 
the  whole  of  what  was  termed  the  external  incision 
is  here  unnecessary.  The  staff  is  straight,  a  com- 
mon probe-pointed  bistoury  is  to  be  introduced  in 
its  groove,  and  a  slight  lateral  incision  made;  the 
finger  is  to  be  passed  in,  the  forceps  along  this,  and 
the  stone  extracted,  as  in  the  male.  There  will  not 
probably  be  any  artery  requiring  ligature. 


38 

It  is  a  disputed  point,  whethef  lithotomy  should 
ever  be  performed  on  a  female.  The  dilatability  of 
the  urethra,  it  is  alleged,  will  make  an  incision  unne- 
cessary "  in  a  young  and  healthy  female  subject,  where 
the  bladder  is  free  from  disease."*  One  obstacle 
will  present  equally  to  both  methods ;  incontinence  of 
urine  very  frequently  occurs  after  both.  In  Mr. 
Thomas'  case  "  the  involuntary  discharge  of  urine 
continued  only  six  hours,"  but  in  some  cases  it  has 
undoubtedly  been  far  more  obstinate.  The  sur- 
geonVdecision  between  the  two  methods  must  be 
guided  by  the  state  of  the  bladder,  and  the  probable 
size  of  the  stone.  If  the  former  be  diseased,  and 
the  latter  very  large,  it  would  be  improper  to  hazard 
a  destruction  of  the  muscular  power  of  the  urethra, 
by  over-distention,  and  an  incision  would  be  pre- 
ferable. If  the  bladder  be  sound,  and  the  stone  rea- 
sonably supposed  to  be  small,  the  trial  of  dilatation 
would  appear  to  be  the  most  eligible  practice.  This 
at  least  is  the  opinion  of  Le  Dran.f  I  need  offer  no 
apology  to  modern  surgeons,  for  not  dwelling  upon 
his  means  of  dilatation,  the  blunt  gorget  and  several 
forceps  increasing  in  size.  This  author  adds,J 
"  Women  are  more  subject  to  this  complaint  (in- 
continence of  urine)  than  men,  as  in  them  the  neck 
of  the  bladder  is  not  invested  with  the  prostate  gland, 
which  strengthens  that  part.  It  is  impossible  to 
avoid  either  dilating  or  dividing  the  orifice  of  the 
bladder  in  order  to  extract  the  stone ;  and  when  the 
stone  is  large,  it  must  necessarily  make  a  dilatation 
and  laceration  proportionable  to  its  bulk,  or  it  could 

*  Mr.  Thomas'  paper,  loc.  cit. 

t  Page  255,  edit.  1781.  *  Page  265. 


39 

not  pass.  This  is  indeed  a  great  misfortune  to  the 
sex,  but  the  only  method  to  prevent  it  is  to  have  re- 
course to  the  operation  in  time,  before  the  stone  is 
arrived  to  any  considerable  size." 


INSTRUMENTS. 

Certain  accidents  not  unfrequently  occur  during 
the  operation,  which  should  make  the  surgeon  very 
careful  in  his  choice  of  instruments.  Some  of  these 
untoward  occurrences  may  be  the  effect  of  a  want  of 
anatomical  knowledge,  or  of  proper  caution.  But 
it  is  evident,  that  some  must  be  occasioned  by  using  a 
faulty  instrument.  My  remarks  on  this  head  shall 
be  entirely  confined  to  a  comparison  between  the 
gorget  and  bistoury.  These  are  the  instruments 
which  chiefly  divide  the  opinions  of  surgeons  at  pre- 
sent. 

The  accident  most  generally  feared,  is  the  thrust- 
ing the  gorget  between  the  bladder  and  rectum,  in 
making  the  second  incision.  This,  it  may  be  said, 
cannot  take  place  if  the  instrument  be  passed  in  the 
direction  of  the  axis  of  the  bladder.  As  I  have  not 
witnessed  the  occurrence,  I  cannot  say  whether  this 
point  has  been  attended  to.  But  it  has  happened  in 
the  hands  of  surgeons  who  had  a  large  share  of  pub- 
lic confidence,  and  whom  we  cannot  reasonably  sus- 
pect of  deficiency.  The  accident  is  not  so  unfre- 
quent  as  has  been  imagined.    Mr.  C.  Bell  relates  that 


40 

he  has  known  it  in  two  cases;*  Mr.  A.  Cooper,  in 
his  lectures,  states,  that  "  near  a  dozen"  instances 
have  come  within  his  knowledge ;  and  I  have  myself 
been  informed  of  others. 

This  occurrence  has  been  explained  by  Mr.  C. 
Bell  from  some  appearances  observed  on  the  dead 
body.  "  The  gorget  had  not  gone  off  the  groove : 
it  had  only  not  cut  the  neck  of  the  bladder,  it  had 
pushed  the  prostate  gland  onwards  upon  the  staff, 
and  had  not  pierced  the  neck  of  the  bladder  nor  the 
prostate  gland. "f  Mr.  J.  Bell  probably  has  this  ex- 
planation in  view,  when  he  speaks  of  forcing  "  off 
the  neck  of  the  bladder  and  prostate  from  the  ure- 
thra;" but  he  also  thinks  it  "  unquestionable  that 
the  gorget  is  often  plunged  among  the  viscera.  "J 
The  probability  is,  that  all  these  varieties  of  the  ac- 
cident may  occur. 

The  explanation  of  the  Bells  would  place  the  fault 
of  such  an  accident  rather  in  the  instrument  than  in 
the  operator.  And  indeed,  whatever  explanation 
we  adopt,  it  must  be  evident,  that  the  gorget  is  very 
liable  to  cause  such  an  occurrence;  not  to  say,  that 
it  appears  calculated  for  it.  A  kind  of  curve  is  de- 
scribed in  thrusting  it  in,  which  must  make  it  act 
with  obvious  disadvantage;  its  edge  striking  ob- 
liquely, will  probably  lacerate  as  many  fibres  as  it 
cuts.  In  the  use  of  the  bistoury  however,  no  such 
occurrence  takes  place.  It  is  so  small  that  it  passes 
with  the  readiness  of  a  sound,  and  as  the  incision  is 
made  in  withdrawing  the  instrument,  it  is  impossi- 


*  Operat.  Surg.  vol.  i.  page  344. 
f  Ibid. 

t  Smith's  Abridgement,  pages  186,  187. 


41 

ble  that  the  prostate  can  yield  before  its  edge.  Not 
to  mention  that  the  edge  of  a  knife  can  be  made  and 
kept  keen  with  far  greater  ease  than  that  of  a  gorget, 
and  will  of  course  be  better  calculated  to  make  a 
real  incision.  We  cannot  suppose  it  possible,  but 
by  the  grossest  ignorance  or  inattention,  that  the 
bistoury  can  be  literally  pushed  between  the  bladder 
and  rectu  im 

Cases  have  occurred,  in  which  the  staff  has  been 
bent  by  an  over-attention  to  keep  the  beak  of  the 
gorget  in  its  groove.  In  the  use  of  the  bistoury, 
this  is  scarcely  possible;  it  enters  with  such  facility, 
that  no  force  is  requisite  to  keep  its  beak  in  contact 
with  the  staff. 

The  gorget  being  an  instrument  of  no  inconsider* 
able  bulk,  must  be  wedged  with  some  firmness  in 
the  wound  it  makes.  This  will  prevent  the  ope- 
rator from  feeling  with  accuracy  when  it  has  entered 
the  bladder;  or  rather,  (as  the  flow  of  urine  will  as- 
certain this)  he  will  not  be  able  to  command  the 
force  with  which  he  thrusts  it  onward.  This  acci- 
dent is  admitted  by  "  those  who  prefer  the  gorget, 
and  regard  it  as  the  ultimate  improvement  of  this 
operation."  It  has  occurred  to  surgeons  whose  cau- 
tion or  knowledge  we  have  no  reason  to  doubt,  and 
it  must  therefore  be,  at  least  in  part,  attributed  to  the 
instrument.  I  need  hardly  add,  that  the  bistoury  is 
free  from  such  an  imperfection;  it  passes  like  a 
probe,  and  is  as  easily  regulated  by  the  surgeon ;  and 
even  were  it  thrust  in,  it  would  be  scarcely  more 
liable  to  pierce  the  bladder  than  a  sound. 

The  above  accident  may  perhaps  be  attributed  to 
the  bladder's  contracting  upon  the  edge  of  the  gor- 
get.   This  edge,  in  every  form  of  that  instrument 

6 


42 

and  those  analogous  to  it,  projects;  which  projec 
tion,  if  the  stone  be  not  between  it  and  the  coats  of 
the  bladder,  may  very  readily  cut  through  the  latter. 
It  is  evident,  that  the  bistoury  is  not  liable  to  this 
accident,  as  its  edge  does  not  project. 

It  may  perhaps  be  objected  to  the  bistoury,  that 
it  gives  no  limit  to  the  incision.  It  truly  does 
not;  and  to  a  surgeon  even  moderately  expert, 
this  would  be  a  recommendation  rather  than  an  ob- 
jection. I  am  not  indeed  certain  that  any  will  cavil; 
if  they  should,  they  must  be  referred  to  the  dead 
subject,  till  they  can  acquire  steadiness  sufficient  to 
handle  a  knife. 

The  gorget,  it  will  be  urged,  unites  a  director 
with  a  cutting  instrument.  It  was  before  stated, 
that  the  advantage  of  such  a  director  was  very 
questionable.  If  the  wound  be  sufficiently  free, 
and  the  patient's  struggles  not  unusually  violent,  the 
finger  upon  the  staff,  and  the  forceps  upon  the  finger, 
will  fully  suffice.  If  the  patient  be  very  fat,  his 
bladder  may  be  too  far  from  the  external  perineum, 
to  be  reached  by  the  finger.  Or  the  surgeon,  how- 
ever expert,  may  possibly  lose  the  direction  of  the 
incision.  In  this  case,  a  blunt  gorget  will  be  an  use- 
ful instrument.  But  the  occasion  for  a  director  will 
be  very  rare,  and  the  bistoury  in  all  other  cases  will 
amply  suffice, 

I  am  sensible,  that  although  the  knife  is  preferred 
by  surgeons  of  great  eminence,  the  gorget  has  ad- 
vocates equally  great.  With  so  even  a  defence  on 
both  sides,  it  might  be  deemed  presumption  to  offer 
an  unreserved  decision.  So  far  however  as  I  am  ac- 
quainted with  the  opinions  of  each,  I  am  disposed 
tp  think  that  the  bistoury  is  ljable  to  fewer  objections 


4<3 

than  any  other  instrument  with  whose  use  I  am  ac- 
quainted. 

Thus  far  the  knives  both  of  Mr.  Blizard  and  Mr, 
Cooper  have  been  equally  advocated ;  and  from  the 
similarity  of  principle,  it  would  be  difficult  to  choose 
between  them.  There  are  however  some  minutice  in 
that  of  the  former,  which  will  make  it,  on  the  whole, 
preferable;  or  perhaps  I  may  think  so,  from  being 
accustomed  to  its  use  on  the  dead  body.  As  its 
beak  projects  a  little  from  the  upper  part  of  its  point, 
it  may  be  introduced  more  nearly  parallel  with  the 
staff.  As  it  is  rounded  for  near  an  inch  from  the 
beak,  it  will  follow  with  greater  certainty  the  canal 
of  the  urethra,  and  will  "  make  assurance  doubly 
sure,"  that  the  parietes  of  the  bladder  will  not  be  cut. 
As  also  it  is  straight,  it  is  better  calculated  to  make 
a  ready  incision. 

These  instruments  have  both  been  repeatedly  used 
with  success;  so  that  no  circumstance,  either  in 
theory  or  in  experiment,  is  wanting  to  embolden 
a  surgeon  in  adopting  them.  Of  operators,  how- 
ever, who  have  long  used  the  gorget,  and  who  are 
satisfied  with  their  practice,  it  would  be  unreason- 
able to  ask  a  change.  A  younger  surgeon  will  ba- 
lance in  his  own  mind  the  comparative  merits  of  the 
two;  and  as  he  has  "  proved"  neither,  will  adopt 
that  in  which  he  places  the  greatest  confidence.  The 
first  duty  of  every  practitioner  is  to  render  operations 
unnecessary.  When  these  efforts  are  unavailing,  he 
is  to  free  them  from  danger  as  much  as  possible. 
Anatomical  knowledge,  and  well-established  theory, 
are  undoubtedly  the  most  important  means  of  effect- 
ing the  latter;  but  it  must  be  evident  that  there  is  a 
preference  among  instruments, — in  what  operation 


44 

more  than  in  lithotomy?  It  has  been  advanced,  that 
the  gorget  is  a  knife ;  if  so,  it  is  a  very  clumsy  one. 
The  use  of  such  an  argument  is  a  tacit  consent  to  the 
superiority  of  the  latter  instrument.  And  I  know 
not  what  higher  praise  could  be  bestowed  upon  the 
bistoury,  than  retorting,  that  it  is  not  a  gorget* 


THE  END, 


i,K  Hv.Lt, 


\^  E 


- 


* 


O  S 

00  m 

■fa.  J 

CO  m 


JUL    21942 


